The pandemic has highlighted many problems in the NZ health system. This blog will address the question of availability of interpreters for people with limited English proficiency (LEP). This is now funded within hospitals. It is funded in Primary Care in Auckland and Nelson but not other regions. It became clear that interpreters were needed to enable Primary Care to look after Covid-19 patients in the community and the Ministry of Health has provided central funding throughout the country for this purpose. If it is acknowledged that funded interpreters are needed for Covid-19 patients, why are they not available for other conditions?
Experience in the Covid-19 pandemic has highlighted a number of important issues in our health care system. There has been a lot of focus on inequitable outcomes particularly for Māori and Pacific populations [1]. We know about this inequity because we collect data.
There is an important sector of our population for whom we have very limited data but who intuitively must have inferior health care; those with a language barrier. Whilst there are some bilingual providers in general, this is the group of people who have limited English proficiency (LEP).
How can a clinician provide good care if they cannot talk to their patient?
HOW MANY INTERPRETERS DO WE NEED?
We have very imprecise information on how many people might require interpreter services. The census asks questions about language and we know that 1.9% (4.4% in Auckland) speak only one language that is not English. These people cannot manage without an interpreter. There are another 16% (27% in Auckland) who speak two or more languages but not Māori or NZ Sign Language. Most of this group will speak English and another language, but an unknown number of these people do not speak enough English to receive adequate health care. Australia has similar numbers of migrants, and their census (2016) asks more useful questions. 3.5% replied that they speak another language and English not at all well, 17% speak another language and English well or very well and 6.4% did not reply. A reasonable guesstimate of how many would need an interpreter for a consultation would be 5% of the population. If that was applied to NZ that would be 235,000 people.
INTERPRETER UTILISATION
The Government does not collate data on interpreter utilisation. I have contacted all the DHBs, interpreter providers and Ministry of Business Innovation and Employment (MBIE) Language Assistance Programme to try to establish what is currently provided. The data are of poor quality but there were at least 250,000 interpreted consultations per year in DHBs and Primary Care. We do not know what average number of consultations per year can be expected. However, given that the person with the highest numbers of interpreted consultations in Nelson had 69 consultations in one year, a rate of one interpreted consultation per person per year for all health care is clearly inadequate.
HEALTH AND DISABILITY CONSUMERS’ CODE OF RIGHTS
Right 5 gives a right to effective communication. Where necessary and reasonably practicable, this includes the right to a competent interpreter. When the code of rights was established, most interpreting was in person and this was the reason for the “reasonably practical” qualification. It is very difficult for a clinician to assess the competence of an interpreter, other than knowing what training and certification they have. Now with the availability of professional telephone and video interpreters it is no longer tenable in most circumstances not to use a professional interpreter.
INTERPRETERS PROVIDED AND FUNDED IN HOSPITAL
The problem of inequity because of a language barrier can be largely resolved by the provision of interpreters and MBIE has a language assistance programme. They have contracted Ezispeak to provide interpreting services to the core public service 24/7. In the health sector this means that all hospitals have access to interpreters. The predominant modality is telephone interpreting, but this has recently been extended to in-person interpreting.
INTERPRETERS NOT FUNDED IN PRIMARY CARE
The Ezispeak service is not available to Primary Care. In Primary Care there is no explicit budget for interpreting services and Primary Health Organisations (PHOs) are expected to enter their own contracts with language providers. There is a small budget for “Services to Improve Access” (SIA) that is only available to Māori, Pacific and people in deprivation index quintile 5 (the most deprived quintile). Access to interpreters differs around the country. The three Auckland DHBs and Nelson DHB provide funding for Primary Care Interpreting from the DHB budget (and in Nelson’s case, a contribution from PHO SIA funding). Given that a large proportion of those needing an interpreter live in Auckland this is great. However, it is a classic case of post code health care; of quality of access determined by where you live.
Even with full funding Australia has poor uptake of interpreters in Primary Care and has proposed strategies to improve this. Without proper funding our uptake in NZ is likely to be much worse.
INTERPRETERS AND COVID-19
Because of the epidemic nature of Covid-19 if a person receives poor care through lack of an interpreter, this can have a major effect on the whole community.
We know that the Delta outbreak in Auckland was significantly within the Pacific community. What we do not know is what proportion of those affected did not speak English. However, the outbreak was only able to be controlled once the providers in the Pacific community were given the resources to address these issues. Dr Api Talemaitoga a GP in South Auckland said:
During the first lockdown, he says some patients would tell their GP they had got a call, “from someone they don’t know from a place they had never heard of, speaking palagi about things they don’t understand, ‘and I just said yes to get them off the phone’”.
Now that there is significant Covid-19 in the community a new need has been identified. The health system has relied on Primary Care to care for most of these people. A lot of that care is being provided remotely. Providers of care to patients that do not have language congruent clinicians identified to the Ministry of Health that they were unable to do this without interpreters.
FULL INTERPRETER FUNDING FOR PATIENTS WITH COVID-19 IN PRIMARY CARE
As a result, the Ministry of Health announced an initiative to fully fund interpreting for Primary Care Services caring for people suffering from Covid-19.
Like the approach of funding Pacific Services to do the contact tracing this has come about because the nature of Covid-19 is that inequities in access cause consequences not just to the community affected but to the whole of the team of 5 million.
WHY DO WE NOT FUND INTERPRETERS IN PRIMARY CARE ALL THE TIME?
If funded interpreting is needed to provide satisfactory care for patients with Covid-19 why is it not available to provide care for all other conditions?
NZ has accepted refugees from all over the world over the last 30 years. On arrival most do not speak English. Nelson DHB introduced its funded Primary Care interpreting as a result of accepting refugees into the region. But what about refugees outside of Auckland and Nelson?
An important issue addressed by the Royal Commission of Inquiry into the terrorist attack on Christchurch masijidain was the importance of social inclusion. They identified that both the perpetrator and the victims would have benefited from greater social inclusion. It is not possible for a person with limited English proficiency to be socially included without interpreters.
Australia has had a fully-funded national interpreting service for the last 50 years. Why are we taking so long to provide this essential basic service in Primary Care?
* Author details: Associate Professor Ben Gray is with the Department of Primary Care and General Practice, University of Otago Wellington
Acknowledgement
This work was funded by Tū Ora Compass PHO.
